1. This study investigated the effects of intermittent antegrade aortic root and graft cardioplegic delivery combined with early graft perfusion of warm arterial blood during coronary artery bypass grafting (CABG).
2. Patients receiving this combined cardioplegic delivery and graft perfusion technique had shorter cardiopulmonary bypass times, lower need for defibrillation and inotropic support, and lower biomarkers of myocardial injury compared to patients receiving antegrade aortic root cardioplegia alone.
3. The study concludes that this combined cardioplegic delivery and graft perfusion technique may provide better myocardial protection and outcomes for patients undergoing CABG, especially those with multi-vessel disease or poor ventricular function. However, more
STICH (Surgical Treatment for Ischemic Heart Failure)theheart.org
- Population and treatment:
1212 patients with coronary artery disease amenable to coronary artery bypass graft (CABG) with LVEF <35%
Randomized to CABG or standard medical therapy alone
- Primary outcome:
All-cause death
STICH myocardial viability substudy:
- A substudy designed to determine whether substantial viable myocardium evident at baseline (visualized by SPECT imaging or dobutamine echo) affects all-cause mortality over five years or influences the relative effectiveness of the selected treatment strategy
See the article at http://www.theheart.org/article/1204899.do
bentall, and 'old' procedures that still valid until present. Bail out for valve sparring & the patology of indonesian most present were best in this procedures
Hemorrhage is the leading cause of preventable death following trauma. Non-compressible hemorrhage is of particular concern as these patients require emergent intervention and many will die prior to anatomic hemostasis. For years, left anterior thoracotomy, the “ED thoracotomy”, was the standard of care for temporary proximal aortic occlusion, but survival remained dismal. Endoluminal aortic occlusion which was actually first described in the 1950s. With the increasing use of endovascular therapies for a wide variety of vascular disease, the “REBOA” (Resuscitative Endovascular Balloon Occlusion of the Aorta) began to be reported for use for ruptured abdominal aneurysms in the 2000s. Since that time, interest in its use in trauma has been increasing with a variety of basic science studies and early clinical series and case reports documenting potential benefits. Although no large randomized trials, or even large observational studies, are available, use of the REBOA is considered standard of care in many centers. Typically the REBOA is placed via the femoral artery either percutaneously or via a cut down and the aorta is occluded with a balloon placed over a wire by standard Seldinger-type technique. The balloon can be placed in “zone 1” just above the diaphragm to provide occlusion to the abdominal viscera and pelvic vasculature or in “zone 3” at the aortic bifurcation to provide inflow control to the pelvis and lower extremities. Injuries are then addressed and the balloon is carefully deflated taking care to avoid metabolic collapse from reperfusion. One main limitation of this technique is that the currently approved device in the United States requires a 12F sheath which requires an open femoral artery repair which obvious can be associated with significant complications. There are a huge number of unanswered questions about the use of REBOA in 2015:
1. Who are the appropriate patients in whom use may be beneficial?
2. How long can a balloon be inflated and the aorta be occluded before irreversible ischemic damage to the viscera occurs?
3. How long can the aorta be occluded before the metabolic consequences of reperfusion are lethal?
4. What is the effect on cerebral and cardiac perfusion when a REBOA is placed and afterload is acutely increased? Is it favorable or “too much”?
5. Who are the appropriate providers to place a REBOA? Only surgeons? Emergency Medicine physicians? Medics in the field?
6. How do we best train providers to place the REBOA?
7. How to we assure competency of providers?
8. Will lower profile devices make the technique more accessible and be associated with fewer complications?
STICH (Surgical Treatment for Ischemic Heart Failure)theheart.org
- Population and treatment:
1212 patients with coronary artery disease amenable to coronary artery bypass graft (CABG) with LVEF <35%
Randomized to CABG or standard medical therapy alone
- Primary outcome:
All-cause death
STICH myocardial viability substudy:
- A substudy designed to determine whether substantial viable myocardium evident at baseline (visualized by SPECT imaging or dobutamine echo) affects all-cause mortality over five years or influences the relative effectiveness of the selected treatment strategy
See the article at http://www.theheart.org/article/1204899.do
bentall, and 'old' procedures that still valid until present. Bail out for valve sparring & the patology of indonesian most present were best in this procedures
Hemorrhage is the leading cause of preventable death following trauma. Non-compressible hemorrhage is of particular concern as these patients require emergent intervention and many will die prior to anatomic hemostasis. For years, left anterior thoracotomy, the “ED thoracotomy”, was the standard of care for temporary proximal aortic occlusion, but survival remained dismal. Endoluminal aortic occlusion which was actually first described in the 1950s. With the increasing use of endovascular therapies for a wide variety of vascular disease, the “REBOA” (Resuscitative Endovascular Balloon Occlusion of the Aorta) began to be reported for use for ruptured abdominal aneurysms in the 2000s. Since that time, interest in its use in trauma has been increasing with a variety of basic science studies and early clinical series and case reports documenting potential benefits. Although no large randomized trials, or even large observational studies, are available, use of the REBOA is considered standard of care in many centers. Typically the REBOA is placed via the femoral artery either percutaneously or via a cut down and the aorta is occluded with a balloon placed over a wire by standard Seldinger-type technique. The balloon can be placed in “zone 1” just above the diaphragm to provide occlusion to the abdominal viscera and pelvic vasculature or in “zone 3” at the aortic bifurcation to provide inflow control to the pelvis and lower extremities. Injuries are then addressed and the balloon is carefully deflated taking care to avoid metabolic collapse from reperfusion. One main limitation of this technique is that the currently approved device in the United States requires a 12F sheath which requires an open femoral artery repair which obvious can be associated with significant complications. There are a huge number of unanswered questions about the use of REBOA in 2015:
1. Who are the appropriate patients in whom use may be beneficial?
2. How long can a balloon be inflated and the aorta be occluded before irreversible ischemic damage to the viscera occurs?
3. How long can the aorta be occluded before the metabolic consequences of reperfusion are lethal?
4. What is the effect on cerebral and cardiac perfusion when a REBOA is placed and afterload is acutely increased? Is it favorable or “too much”?
5. Who are the appropriate providers to place a REBOA? Only surgeons? Emergency Medicine physicians? Medics in the field?
6. How do we best train providers to place the REBOA?
7. How to we assure competency of providers?
8. Will lower profile devices make the technique more accessible and be associated with fewer complications?
The field of perfusion is becoming increasingly demanding both clinically and didactically. As the patient population continues to present with a variety of complex health issues, there is a greater need than ever for the Pefusionist to develop new techniques for patient care while on Cardiopulmonary Support. Ascending Aortic Arch dissections (AAAD), with its current mortality rates of 10%-15% with significant neurological complications associated, still remains a difficult case for Perfusionist’s to manage effectively. The most widely used technique during this type of repair surgery, is hypothermic circulatory arrest (HCA). Although this remains a premier technique, there continues to be a high reported incidence of neurological deficit post HCA. In order to address and limit this issue, the advent of selective cerebral perfusion is slowly gaining acceptance. This new technique has been shown to not only decrease the time of exposure of blood to a foreign surface, but limit the patient duration on full cardiopulmonary support. The most notable aspect of this technique; is it allows the surgeon to begin repairs immediately, since the process cools the brain only, while keeping the rest of body at moderate-mild hypothermic levels.
Initial Care of the Severely Injured Patient by new technique REBOASurendra Patel
THIS PRESENTATION DESCRIBE A GLIMPSE OF NEW TECHNIQUE CALLED AS REBOA-Resuscitative Endovascular Balloon Occlusion of the Aorta. A rapidly emerging technique to control noncompressible, intracavitary hemorrhage below the diaphragm. A less invasive alternative to emergency thoracotomy and aortic cross-clamping for a patient who is hemodynamically compromised but does not have evidence of thoracic hemorrhage and is not in arrest. An aortic occlusion balloon is rapidly placed into the aorta through percutaneous or open access to the common femoral artery, usually during initial triage.
Acute type A dissection, is on of the highest mortality cases in cardiovascular surgery. It doubled it incident with concomitant complication such as malperfusion or pericardial tamponade. In this presentation, the patient have both coronary malperfusion and pericardial tamponade
Myocardial viability testing all STICHed up, or about to be REVIVEDNicolas Ugarte
Patients with ischaemic left ventricular dysfunction frequently undergo myocardial viability testing. The historical model presumes that
those who have extensive areas of dysfunctional-yet-viable myocardium derive particular benefit from revascularization, whilst those without extensive viability do not. These suppositions rely on the theory of hibernation and are based on data of low quality: taking a dogmatic
approach may therefore lead to patients being refused appropriate, prognostically important treatment. Recent data from a sub-study of
the randomized STICH trial challenges these historical concepts, as the volume of viable myocardium failed to predict the effectiveness of
coronary artery bypass grafting. Should the Heart Team now abandon viability testing, or are new paradigms needed in the way we interpret viability? This state-of-the-art review critically examines the evidence base for viability testing, focusing in particular on the presumed
interactions between viability, functional recovery, revascularization and prognosis which underly the traditional model. We consider
whether viability should relate solely to dysfunctional myocardium or be considered more broadly and explore wider uses of viability testingoutside of revascularization decision-making. Finally, we look forward to ongoing and future randomized trials, which will shape evidence-based clinical practice in the futur
Thrombus aspiration during percutaneous coronary intervention (PCI) for ST-segment elevation myocardial infarction (STEMI) is said to reduce PCI-induced distal occlusion.
In an attempt to enhance its effectiveness, thrombus aspiration is often coupled with glycoprotein IIb/IIIa (GP IIb/IIIa) inhibitors, although conflicting results with this strategy have been reported.
GP IIb/IIIa antagonists inhibit the final common pathway that leads to platelet aggregation and leukocyte plugging, which are the main components of fresh thrombi.
The field of perfusion is becoming increasingly demanding both clinically and didactically. As the patient population continues to present with a variety of complex health issues, there is a greater need than ever for the Pefusionist to develop new techniques for patient care while on Cardiopulmonary Support. Ascending Aortic Arch dissections (AAAD), with its current mortality rates of 10%-15% with significant neurological complications associated, still remains a difficult case for Perfusionist’s to manage effectively. The most widely used technique during this type of repair surgery, is hypothermic circulatory arrest (HCA). Although this remains a premier technique, there continues to be a high reported incidence of neurological deficit post HCA. In order to address and limit this issue, the advent of selective cerebral perfusion is slowly gaining acceptance. This new technique has been shown to not only decrease the time of exposure of blood to a foreign surface, but limit the patient duration on full cardiopulmonary support. The most notable aspect of this technique; is it allows the surgeon to begin repairs immediately, since the process cools the brain only, while keeping the rest of body at moderate-mild hypothermic levels.
Initial Care of the Severely Injured Patient by new technique REBOASurendra Patel
THIS PRESENTATION DESCRIBE A GLIMPSE OF NEW TECHNIQUE CALLED AS REBOA-Resuscitative Endovascular Balloon Occlusion of the Aorta. A rapidly emerging technique to control noncompressible, intracavitary hemorrhage below the diaphragm. A less invasive alternative to emergency thoracotomy and aortic cross-clamping for a patient who is hemodynamically compromised but does not have evidence of thoracic hemorrhage and is not in arrest. An aortic occlusion balloon is rapidly placed into the aorta through percutaneous or open access to the common femoral artery, usually during initial triage.
Acute type A dissection, is on of the highest mortality cases in cardiovascular surgery. It doubled it incident with concomitant complication such as malperfusion or pericardial tamponade. In this presentation, the patient have both coronary malperfusion and pericardial tamponade
Myocardial viability testing all STICHed up, or about to be REVIVEDNicolas Ugarte
Patients with ischaemic left ventricular dysfunction frequently undergo myocardial viability testing. The historical model presumes that
those who have extensive areas of dysfunctional-yet-viable myocardium derive particular benefit from revascularization, whilst those without extensive viability do not. These suppositions rely on the theory of hibernation and are based on data of low quality: taking a dogmatic
approach may therefore lead to patients being refused appropriate, prognostically important treatment. Recent data from a sub-study of
the randomized STICH trial challenges these historical concepts, as the volume of viable myocardium failed to predict the effectiveness of
coronary artery bypass grafting. Should the Heart Team now abandon viability testing, or are new paradigms needed in the way we interpret viability? This state-of-the-art review critically examines the evidence base for viability testing, focusing in particular on the presumed
interactions between viability, functional recovery, revascularization and prognosis which underly the traditional model. We consider
whether viability should relate solely to dysfunctional myocardium or be considered more broadly and explore wider uses of viability testingoutside of revascularization decision-making. Finally, we look forward to ongoing and future randomized trials, which will shape evidence-based clinical practice in the futur
Thrombus aspiration during percutaneous coronary intervention (PCI) for ST-segment elevation myocardial infarction (STEMI) is said to reduce PCI-induced distal occlusion.
In an attempt to enhance its effectiveness, thrombus aspiration is often coupled with glycoprotein IIb/IIIa (GP IIb/IIIa) inhibitors, although conflicting results with this strategy have been reported.
GP IIb/IIIa antagonists inhibit the final common pathway that leads to platelet aggregation and leukocyte plugging, which are the main components of fresh thrombi.
The intent of this presentation is to provide an update of coronary assessment and management for the adult intensivist. Discussion points will include:
1. An assessment of coronary severity, using established methods, in particular fractional flow reserve (FFR),
2. Which stent- highlight the evolution of the stent to the current generation and what is evolving,
3. How to keep the stent open with current concepts of antiplatelet therapy and how this impacts the critically ill patient
4. What to consider if the ECG is abnormal, but the coronaries are not flow limiting obstruction- an occasional dilemma in the critically ill patient and finally
5. Discussion around a contemporary study regarding cardiogenic shock and coronary ischemia.
Transcatheter Aortic-Valve Replacement with a Balloon-Expandable Valve in Low...Shadab Ahmad
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Dr Hans Groth, Chairman of the Board, World Demographic & Ageing Forum
Professor Ilona Kickbusch, Founder and Chair, Global Health Centre, Geneva Graduate Institute and co-chair, World Health Summit Council
Dr Natasha Azzopardi Muscat, Director, Country Health Policies and Systems Division, World Health Organisation EURO
Dr Marta Lomazzi, Executive Manager, World Federation of Public Health Associations
Dr Shyam Bishen, Head, Centre for Health and Healthcare and Member of the Executive Committee, World Economic Forum
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This document is designed as an introductory to medical students,nursing students,midwives or other healthcare trainees to improve their understanding about how health system in Sri Lanka cares children health.
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Collaborations and partnerships among leading companies play a pivotal role in driving the growth of the India Diagnostic Labs Market. These strategic alliances allow companies to merge their expertise, strengthen their market positions, and offer innovative solutions. By combining resources, companies can enhance their research and development capabilities, expand their product portfolios, and improve their distribution networks. These collaborations also facilitate the sharing of technological advancements and best practices, contributing to the overall growth of the market.
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The expansion of diagnostic chains is a driving force behind the growing demand for diagnostic lab services. Diagnostic chains often establish multiple laboratories and diagnostic centers in various cities and regions, including urban and rural areas. This expanded network makes diagnostic services more accessible to a larger portion of the population, addressing healthcare disparities and reaching underserved populations. The presence of diagnostic chain facilities in multiple locations within a city or region provides convenience for patients, reducing travel time and effort. A broader network of labs often leads to reduced waiting times for appointments and sample collection, ensuring that patients receive timely and efficient diagnostic services.
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LGBTQ+ Adults: Unique Opportunities and Inclusive Approaches to CareVITASAuthor
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Effect of Cardioplegic Infusion of Antegrade Aortic Root and Bypass Graft Combined With Passive Graft Perfusion in On-Pump CABG
1. Effect of Cardioplegic Infusion of
Antegrade Aortic Root and Bypass
Graft Combined With Passive Graft
Perfusion in On-Pump CABG
Tugrul Göncü1, Mustafa Günes1, Mustafa Sezen1, Hasan Ari2, Faruk
Toktas1, Ahmet Demir1, Osman Tiryakioglu1, Hakan Vural1, Senol
Yavuz1, Ahmet Ozyazicioglu1
1Department of cardiovascular Surgery, Bursa Yuksek Ihtisas
Education and Research Hospital, Bursa, Turkey
2. Introduction
• Coronary artery bypass grafting (CABG) performed with
the aid of cardioplegia and cardiopulmonary bypass
(CPB) requires a period of cardiac arrest.
• During this time, myocardial ischemia may occur, which
is an important determinant of functional and clinical
outcome [1]
• Both the duration of the periodof aortic clamping and
the duration of cardiopulmonary bypasshave been
consistently shown to be the main determinants of
postoperative outcomes of cardiac surgery [2-4].
Göncü ve Ark.1
3. • Antegrade cardioplegia remains the single most
widespread mode of administration to protect
the myocardium during cardiac surgical
procedures [5].
• However, in patients with severe coronary artery
disease, cardioplegia maldistribution can occur
withthe use of antegrade cardioplegia alone [6-8]
• These potential problems may be overcome by
direct delivery of cardioplegia via grafts.
Göncü ve Ark.1
4. • In this study, our aim was to investigate the
beneficial effects of intermittent antegrade
aortic root and graft cardioplegic delivery
combined with early perfusion of the grafted
ischemic myocardial segments with warm
arterial blood during the construction of
proximal graft anastomosis on myocardial
protection and performance in on-pump
CABG procedures.
Göncü ve Ark.1
5. MATERIALS AND METHODS
• A prospective, randomized clinical trial was
planned.
• Following the permission of the Institutional
Review Board of our hospital, between June
2006 and October 2009, 96 patients
undergoing on-pump CABG were randomly
divided into two groups consisting of 48
patients each.
Göncü ve Ark.1
6. • Group A (n=48) received antegrade cardioplegic
infusion via the aortic root;
• Group B (n=48) received antegrade cardioplegic
infusion via the aortic root supplemented with
antegrade perfusion of vein or free arterial grafts
after each distal anastomosis was completed.
Additionally, graft perfusion with warm arterial
blood was applied after the cross-clamp until the
proximal anastomosis was completed.
Göncü ve Ark.1
7. The use of a multiple
perfusion set (MPS) in
group B patients
•In this technique, the aortic perfusion
branch of the MPS is kept clamped
during the cross-clamp period, and
each vein or free artery graft is
perfused in an antegrade fashion
following completion of distal
anastomosis in addition to
cardioplegia being administered from
the aortic root.
After the cross-clamp is taken off, the
clamp on the aortic branch is removed
and early perfusion with warm arterial
blood is initiated.
Göncü ve Ark.1
8. • The groups were compared by clinical and
biochemical markers of ischemic myocardial
damage.
Göncü ve Ark.1
9. RESULTS
Patients in each group were similar
with respect to most of the
preoperative characteristics
Göncü ve Ark.1
10. At the end of cardiopulmonary bypass,
most of the data were similar between
the two groups. No statistically significant
differences were noted between the
mean number of distal anastomoses or
mean aortic cross-clamp and partial
occluding clamp times.
However, the mean CPB time in group B
was significantly lower than that of group
A (82.9±13.4 min in group A vs. 75.1±16.5
min in group B, p=0.01).
After declamping the ascending aorta,
sinus rhythm returned spontaneously
without electrical defibrillation in 21
patients (43.8%) from group A as
compared with 41 (85.4%) from group B
(p<0.001). Conversely, 27 patients
(56.2%) from group A and 7 patients
(14.6%) from group B needed
defibrillation after aortic declamping. The
need for defibrillation was significantly
higher in group A (p<0.001).
The number of patients who did not
require any inotropic support was
statistically higher in group B (p= 0.03).
There was no significant difference
between the two groups in regards to the
number of patients requiring low or
medium dose inotropic support.
However, more patients who underwent
antegrade aortic root cardioplegic
delivery alone required a high dose of
inotropic support (p= 0.02).
Göncü ve Ark.1
11. After surgery, there were significant increases in the
peak serum CK-MB and cTn-I levels in both groups,
indicating myocardial injury (p=0.002 in group A and
p=0.008 in group B). When compared to group A, group
B showed lower peak levels of cTn-I and CK-MB at 12
hours (p=0.01 and p=0.02, respectively).
After surgery, there were significant increases in the
peak serum CK-MB and cTn-I levels in both groups,
indicating myocardial injury (p=0.002 in group A and
p=0.008 in group B). When compared to group A, group
B showed lower peak levels of cTn-I and CK-MB at 12
hours (p=0.01 and p=0.02, respectively).
After surgery, there were significant increases in the peak serum CK-MB and cTn-I levels in both groups,
indicating myocardial injury (p=0.002 in group A and p=0.008 in group B). When compared to group A, group
B showed lower peak levels of cTn-I and CK-MB at 12 hours (p=0.01 and p=0.02, respectively).
Göncü ve Ark.1
12. • The peak serum cTn-I and CK-MB level differences were more significant in
the subgroup analysis at 12 hours. In the subgroup of severe right coronary
artery stenosis (>90%), CK-MB: p=0.007 and cTn-I: p=0.008 (Figures A and B),
and in the subgroup of low left ventricular ejection fraction (30-40%), CK-MB:
p=0.002 and cTnI: p=0.004 (Figures C and D).
Göncü ve Ark.1
13. • In regards to the echocardiographic data taken on the sixth
postoperative day, both types of myocardial protection techniques
demonstrated minimal improvement in the left ventricle ejection
fractions. Mean preoperative LVEF% values were: group A,
47.7±8.5; group B, 48.4±9.4 (p=0.64). Mean postoperative LVEF%
values were: group A, 48.9±7.9; group B, 51.7±7.6 (p=0.08).
• The mean length of intensive care unit stay was: group A, 2.72±0.53
days vs. group B, 2.54±0.35 days (p=0.04); mean hospital stay was:
group A, 7.58±1.4 days vs. group B 7.08±0.8 days (p=0.04).
• There were three hospital mortalities between 3-15 days
postoperation: one (2.08%) in group A due to mesenteric infarction
and two (4.16%) in group B due to generalized sepsis and multi-
organ dysfunction.
Göncü ve Ark.1
14. Discussion
• In the present study, we have applied a technique similar to
the method Goldman et al. first described in 1987 [20].
• Our version of the technique facilitates antegrade selective
cardioplegia perfusion by means of free grafts following
each distal anastomosis in addition to antegrade
cardioplegia administered from the aortic root in the
beginning.
• This technique can also supply blood flow to the ischemic
myocardium during construction of the proximal graft
anastomosis, promoting early reperfusion and rapid
recovery of grafted ischemic myocardial regions, which may
decrease ischemia time.
Göncü ve Ark.1
15. • Our findings are in accord with the suggestion that
selective antegrade graft cardioplegia may lead to lower
rates of myocardial injury by homogenous distribution of
cardioplegia solution, especially in areas of critical coronary
artery stenosis or complete coronary artery occlusion.
• In addition to this, our technique facilitates earlier warm
blood perfusion of the grafts, and thus the ischemic
myocardial areas, until the proximal anastomosis is
performed and the cross-clamp is taken off.
• Together, these factors may lead to a lower rate of
ischemia-reperfusion injury, earlier recovery from
myocardial deterioration, and a minimized risk of post-
ischemic myocardial dysfunction.
Göncü ve Ark.1
16. CONCLUSION
• We believe that our technique may prove useful
in lowering the mortality and morbidity rates
following surgery in patients with multi-vessel
coronary artery stenosis and poor ventricular
function when compared with other myocardial
preservation methods.
• Combined with our technique, retrograde
cardioplegia may improve this preservation even
more. However, we believe that further studies
with a larger group of patients are needed to
reach a definitive conclusion.
Göncü ve Ark.1